beth a. moses bsn, rn, aemt trauma injury prevention/ · pdf fileems burn care beth a. moses...
TRANSCRIPT
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EMS BURN CARE
Beth A. Moses BSN, RN, AEMT
Trauma Injury Prevention/Education
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Objectives
• Review the structure and function of the skin
• Identify types of burns
• Discuss pre-hospital management of burn victims
• Discuss inter-facility transport of burn victims
• Discuss inhalation injury , chemical exposure
• Identify patients who need the burn center
• Case reviews
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Functions of the Skin
• Skin is the largest organ.
• Functions: – Mechanical barrier
– Protective barrier
– Sensory organ
– Temperature regulation
Epidermis
Dermis
Subcutaneous
Tissue
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SEVERITY OF BURN • Burn injury result of
– Direct injury – Inflammatory response
• Severity depends upon – Extent – Depth – Age – Associated Injuries/ Pre-existing illness – Hands, face, feet, genitalia
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Burn Extent = % Total Body Surface Area
Burn extent is calculated only on individuals with second and third degree burns
Mortality is effected by:
Age Comorbidities %TBSA Burned
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Initial Estimate, 2nd & 3rd Degree: " Rule of Nines”
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Patient’s palmar surface (hand + fingers)
1% TBSA
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• Temperature of
agent
• Duration of contact
• Dermal thickness
• Blood supply
Special consideration:
Very young or elderly patients
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• Epidermis only
• Pain & redness
• Heals in few days; outer
injured epithelial cells peel
• Seldom clinically significant
First Degree
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• Entire epidermis & portion of dermis
• Pain, blisters, moist, capillary refill delayed
• Uninjured dermis & epidermis, appendages at risk
Second Degree
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• May Heal spontaneously in weeks. Epithelial growth from budding surface and wound edges – scarring.
• Skin grafts-improve functional & cosmetic outcome, decrease risk of wound infection.
Second Degree
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Entire thickness of epidermis & dermis
Decreased pain, dry,
absent capillary refill
May have eschar
Third Degree
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What is ESCHAR? • Dead tissue
• Tan, brown or black
• Slough or crusty like a scab
• Dry, leathery, tough, inelastic. It is like poking cow hide.
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How deep are these burns? How can you tell?
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What’s the TBSA?
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How deep are these burns?
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How many depths of burn are here?
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Thermal Burns
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Scald Injuries
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CHEMICAL BURNS
• Concentration • Quantity • Contact
– Manner and duration • Mechanism of action • Alkalis • Acids • Organic compounds— petroleum products
Tissue damage factors:
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CHEMICAL BURNS
• Injure the skin • May be absorbed into the
body – Damage internal
organs • May be inhaled
– Lung tissue damage • May have minimal skin
injury and yet cause severe systemic injury
Courtesy of Roy Alson, M.D.
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Alkalis / Bases
• pH >7
• May contain hydroxides, carbonates of sodium, potassium, ammonium, lithium, barium, and calcium.
• Oven cleaners, drain and toilet cleaners, fertilizers, stripping agents, cement bonding agent.
• Damage tissue by liquefaction necrosis and protein denaturation … deeper spread of chemical and progression of the burn. Penetrate more than acids.
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Alkali injury to eye
• Vision threatening
• Continuous irrigation using Morgan lens
• May need to numb the eyes
• Be careful where the run off is going…
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Acids
• pH < 7
• Bathroom cleaners, calcium and rust removers, swimming pools, masonry cleaning, leather tanning.
• Damage human tissue by coagulation necrosis and protein precipitation, causing think leathery eschar
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Organic Compounds
• Phenols, creosote and petroleum products
• Produce contact chemical burns and systemic toxicity
• Cause cutaneous damage due to their solvent action on the fat in cell membranes
• Once absorbed, it can produce harmful effects on the kidneys and liver
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Treatment of Chemical Exposure • BSI precautions. • Remove and bag all
contaminated clothing. • Brush off dry chemical. • Flush with copious amounts
of water. • Wipe or scrape any retained
chemical and irrigate again. • Collect runoff water if
hazardous. •Neutralizing chemical contraindicated; potential of heat
generation •Continue irrigation until pain decreases or until patient is evaluated at a burn center
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• Remove saturated clothing
• Brush off powder agents
• Continuously irrigate area with copious amounts of water
•Neutralizing chemical contraindicated; potential of heat generation •Continue irrigation until pain decreases or until patient is evaluated at a burn center
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Hydrofluoric Acid – The EXCEPTION
• Will liquefy tissues and leach calcium from the bones
• Go to nearest Emergency Room after flushing with water. Calcium gluconate gel must be applied immediately. 1 amp of Calcium Gluconate mixed with a tube of surgiluble.
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Electrical Burns
• Extent of injury depends upon:
–Type of current; AC/DC
–Amount of current
–Path of current
–Duration of contact
IS THE SCENE SAFE?????
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Electrical Tissue Injuries
• Entrance and exit
wounds
• Deep tissue injury
• Fractures
• Cannot determine the
extent of the burn
from the surface burn
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Electrical
• Myoglobin is released (due to muscle damage) in high amounts and is toxic to the kidneys.
• Urine becomes tea or cola colored
• Treat with fluids and sodium bicarb infusions.
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Electrical Injury
• Cardiac arrhythmias are the
most serious immediate
injury that occurs.
• V-Fib
– V-Tach
– PVCs
High-flow oxygen. Monitor heart in all patients with electrical contact. Establish IV access Treat per ACLS guidelines.
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Electrical Burns - Initial Care
• Remove rings, jewelry, piercings, watches
• Remove clothing that has not adhered
• Cool burn. Cover in dry dressings or sheets
• Assess skin color, sensation, cap refill and peripheral pulses hourly in an extremity with circumferential burn, an electrical contact, or abnormal neuro exam.
• Watch for compartment syndrome due to muscle swelling
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Compartment Syndrome
• Swollen and tight extremity, shiny
• Disproportionate pain
• Tingling to numbness
• Cyanosis
• Loss of distal pulse
• Loss of pulse is a late sign. Often too late!
• Treatment is fasciotomy
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Compartments / Pressure Reading
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Fasciotomy
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Circumferential Burns
• Constriction of tissues under the skin
• Burned tissues swell. • Dyspnea can develop if
around the chest. • Assess frequently. • Elevate extremity. • May need escharotomy.
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Signs of Inhalation Injury
• Burns of face or mouth
• Singed facial hair
• Sooty sputum
• Hoarse voice or stridor
• Cough or dyspnea
• History of exposure in enclosed space
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Concern for upper airway obstruction
Pharyngeal edema or burns &/or stridor: high likelihood of airway obstruction
• Most heat damage occurs above vocal cords
• Resulting edema severe: may occlude airway
• Early intubation preferable
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INJURY BELOW THE GLOTTIS
• Almost always a chemical injury
• Aldehydes, sulfur oxides & phosgenes adherent to surface of smoke particles cause direct damage to epithelium of large airways
Severity of damage are clinically
unpredictable based on history & initial exam
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Initial Field Care • Safety is #1 priority.
• Protect yourself and your patient.
• Rescue of victims from burning structure takes priority over all other treatment!
• Remove patient from source of burn.
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Initial Field Care
• Priorities are the same as for other trauma patients.
• Primary Survey first.
– STOP THE BURNING PROCESS
• Cover burn with clean dry sheet.
• Maintain body temperature.
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• Early death is not due to the burn but to…
–Airway compromise
–Smoke inhalation
–Trauma
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Airway, Airway, Airway
• Humidified O2 100% non-rebreather mask
• Maintain low threshold for intubation and high index of
suspicion for airway injury
• Endotracheal intubation indicated if:
–Airway obstruction imminent
– LOC is such that airway protective reflexes are impaired
– Stridor, wheezing, labored respirations
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Can’t tube, lost tube, oh my!
Combitube
LMA
King airway
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I think I’m in, I think I’m in . .
• Visualization
• Breath sounds
• Wave Capnography
• Secure it! Hold it!- tie in place. Note lip line.
• Pulse oximetry with C02 capability
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Results in decreased oxygen delivery to tissues, leading to cerebral and myocardial hypoxia.
Cardiac arrhythmias are the most common fatal occurrence.
Binding affinity >240 times than O2 CARBON MONOXIDE
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Masimo Rad 57
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Management of Carbon Monoxide Intoxication
• Remove patient from source of exposure.
• Administer 100% high flow oxygen
Half life of Carboxyhemoglobin in patients:
• Breathing room air 120-200 minutes
• Breathing 100% O2 30 minutes
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Circulation considerations
• Formation of edema is the greatest initial volume loss
• Burns less than 25%
Edema is limited to the burned region
• Burns >25%
Edema develops in all body tissues, including non-burned areas.
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FLUID RESUSCITATION • Goal: Maintain perfusion to
vital organs • Based on the TBSA, body
weight
• Fluid overload should be avoided – difficult to retrieve settled fluid in tissues and may facilitate organ hypoperfusion
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Fluid resuscitation
• Lactated Ringers - preferred solution
• Contains Na+ - restoration of Na+ loss is essential, Free of
glucose – high levels of circulating stress hormones may cause glucose intolerance
• Fluid volumes may increase in patients with
concominent trauma
• Vascular access: Two large bore peripheral lines
• IO only if necessary.
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FLUID RESUSCITATION
2ml warm LR x weight in kg x % TBSA second and third
degree burns = fluids for 1st 24 hrs
½ in 1st 8 hrs
½ over next 16 hrs
Chronic alcoholics, meth lab injuries, high voltage
electrical injuries, or inhalation injuries may require us to
double fluid. Let burn center decide.
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Resuscitation Response
• Response to fluid resuscitation is determined by urine output
• >30Kg=.5cc/kg/hr
• <30Kg= 1cc/kg/hr
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FLUID RESUSCITATION IN THE FIELD
•IV only if no delay •NS OK •Less than 1 hour transport 500-1000 ml, depending on size of the burn.
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Drug of Choice: Morphine Sulfate Dose: As directed Route: IV Only
PAIN MANAGEMENT
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Initial Field Care
• Remove constricting clothing and jewelry. –Cut around adherent
clothing. • Do not apply anything
to a burn! • Do not delay transport
to start IVs/ fluids.
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Effects of Hypothermia
• Hypothermia may lead to acidosis/coagulopathy
• Hypothermia causes peripheral vasoconstriction and impairs oxygen delivery to the tissues
• Metabolism changes from aerobic to anaerobic
serum lactate serum pH
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Prevention of Hypothermia
• Cover patients with a dry sheet
• Pre-warm transport vehicle
• Administer only warmed IV solutions
• Remove wet / bloody clothing and sheets
• Avoid prolonged irrigation
• Paralytics – unable to shiver and generate heat
• Continual monitoring of core temperature
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Burn Center Transfer Criteria
• Partial Thickness burns >10% TBSA
• Burns that involve the face, hands, feet, genitalia, perineum, or major joints
• Any third degree burns
• Electrical burns, including lightning
• Chemical burns
• Inhalation injury
• Any patients with both burns and trauma should go to ECMC
• Comorbidities
• Burns that will require social, emotional, or rehabilitative intervention
2nd degree burns> 10% TBSA
• Burns to face hands feet genitalia, perineum, major joints
• 3rd degree burns
• Electrical Injuries (lightening included)
• Chemical burns
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Upon arrival to Burn Center
• Showered
• Dead skin and blisters removed
• Dressings applied
• Hydration
• Antibiotics
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Continued Care
• Shower/ whirlpool 1-2x per day
• Debride burns with washcloth or by scraping
• Need beefy tissue with buds.
• Continue until grafts can be applied.
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Skin Grafting
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Skin Grafting
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Skin Source
• Cadaver – temporary measure when a patient does not have enough healthy skin to use or burns may progress further.
• Patient’s own skin- Preferred. Sites can be reused after 3-4 weeks of healing.
• Synthetic Skin- $$$$ and more prone to infection.
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Graft care
• Grafted skin must be kept moist until graft “takes”
• Mineral oil or A&D ointment to moisten and control itch
• Compression garments to smooth the skin. Lubriderm is used with compression garments.
• Garments are worn 23 hrs per day for a year
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Scarring
• Higher risk in African Americans, Asian, and Mediterranean descent. Genetics.
• Failure to wear garments
• Failure to graft some 2nd degree.
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Healed Grafts
• Fragile initially then toughen up
• Sunburn and frostbite easily
• No goosebumps
• Lacerations heal with new scar
• Don’t sweat
• If fat cells destroyed with burn, can’t gain weight in that area.
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• 85 year old male
• Sustained extensive burns when
he threw gasoline on a trash fire.
• Reportedly, on fire running in the
yard before collapsing.
• Extinguished with blankets by a neighbor.
• Most of his body was burned except for most of the head and spotty areas of the trunk and thighs.
CASE 1: HISTORY
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WHAT’S THE TBSA?
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• How will you determine fluid requirements? He weighs 70 kg.
• Where will you place the IV’s ?
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WHAT’S THE DEPTH?
HOW CAN YOU TELL?
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• Why should this concern the medical team?
Circumferential 3rd degree
burns are identified on both
arms and both legs.
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• Does this patient meet Burn Center criteria?
• How should he be transported?
• How should the wounds be dressed?
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• 48 year old man is cleaning paint brushes with gasoline at a stationery tub in his basement when the water heater pilot light ignites gasoline fumes engulfing him in flames.
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WHAT’S THE TBSA?
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HOW DEEP IS THIS BURN?
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DOES THIS INJURY MEET BURN TRIAGE CRITERIA?
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• Does this patient meet Burn Center criteria?
• How should he be transported?
• How should the wounds be dressed?
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Summary • Protect yourself and your patient.
• Treat burn patients as trauma patients.
• Stop the burning process.
• Be alert for inhalation injuries.
• Flush chemical burns adequately.
• Monitor heart in electrical burn patients.
• Maintain body temperature.
• Cover with clean dry sheet.
• PCR!
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Questions?